2.0 Analysis 2.1 Introduction The investigation established that the pilot had considerable flying experience and was considered professional and competent by his peers. He showed a marked concern for flight safety by taking two courses on risk management not required by Transport Canada. The analysis, therefore, concentrates in part on the circumstances that led to the flight being undertaken and continued in conditions where safety was in doubt. 2.2 The Aircraft Although the aircraft was equipped with the instruments necessary for instrument flight, flying the aircraft under instrument conditions would have been exceedingly difficult without a stability augmentation system. Examination of the wreckage and a detailed study of the helicopter components did not reveal any indication that the helicopter had suffered a structural failure, problems with the flight controls, electrical problems, loss of engine power, or fire while in the air. 2.3 Flight Planning Because no fixed-wing aircraft was able to go to the camp and make the return flight at night, it was assumed that the patient could be evacuated only by helicopter. The pilot did not evaluate correctly either the total duration of the flight or the time at which night would fall, because at the time the dispatcher contacted him, it was already too late to go to the camp and return to Kuujjuaq before nightfall. Also, the pilot undertook the flight without obtaining the available information about the observed and forecast weather conditions along the route. The pilot's flight planning was deficient, possibly because he had little time available to prepare the helicopter in response to the emergency and to complete the flight. The pilot and the dispatcher had discussed the possibility of evacuating the patient from the fishing camp by making a short flight to Kangiqsualujjuaq,after which the patient could have been transported by fixed-wing aircraft to Kuujjuaq during the night. However, the pilot agreed to make the flight, knowing that he would land at the camp in daylight and would then decide at that point whether to go to Kangiqsualujjuaq. 2.4 The Flight The reason why, with night falling, the pilot took off from the camp toward Kuujjuaq, rather than toward Kangiqsualujjuaq, could not be determined. Shortly after his arrival at the camp, the pilot indicated that the patient would be evacuated to Kangiqsualujjuaq as he had planned. However, after discussion with the physician, the pilot confirmed that he would return to Kuujjuaq, even though he did not have the qualifications necessary for night flight and the helicopter was not certified for that purpose. This change of destination suggests that the patient's condition was critical and required evacuation to Kuujjuaq without delay. It is likely that the patient's condition influenced the pilot in his decision and that he agreed to undertake the night flight to Kuujjuaq for humanitarian reasons. Specific directives and procedures for carrying out MEDEVAC flights would have helped the pilot to plan the flight better and to make well-informed decisions. In general, hospitals and medical personnel are not concerned by aeronautical factors, but rather by the medical condition of their patients, particularly when the decision to evacuate them must be made. Many of them are unaware of the factors that can affect flight safety, such as air regulations, the weather, instrument flight, or night flight. Helicopters are considered merely vehicles for transporting the sick or injured. For their part, although pilots may have little medical knowledge, no pilot can remain insensitive to the condition of a patient requiring evacuation without delay, making it particularly difficult for a pilot to decide whether or not to undertake a flight when it is a MEDEVAC one. In the absence of specific directives regarding MEDEVAC flights, the pilot had to make an operational decision on his own, at a time when his judgement may have been coloured by the pressure of the mission. Because of the apparent urgency of evacuating the patient to Kuujjuaq and the difficulty of communicating with Kuujjuaq by HF to obtain more information, the pilot probably judged it appropriate to make the night flight in violation of the regulations in effect. 2.5 Meteorological Conditions The pilot undertook the flight to the fishing camp without finding out about the observed and forecast weather conditions along the route. The pilot stated that the trip to the camp had taken place in conditions of fog and drizzle similar to those prevailing at the camp when he arrived. The return flight was made over an uninhabited area, on a dark night, under an overcast sky and in marginal conditions. The fact that the pilot delayed the expected time of arrival in Kuujjuaq by ten minutes indicates that he had reduced the helicopter's speed. That speed reduction was probably a result of the adverse conditions encountered. In continuing his path to the west, the pilot was likely faced with reduced visibility in shower conditions similar to those observed by the pilot of the Aztec shortly after the crash. The pilot continued the night flight in adverse weather conditions which he was not able to recognize in time because of the low light level. 2.6 Impact with the Ground The pilot was taking a great risk of losing sight of the ground in the existing environmental conditions. Because he was not IFR qualified and was not experienced in instrument flying, the pilot could not fly using only the flight instruments with which the helicopter was equipped; also, without a proper external visual reference, the pilot was subject to spatial disorientation. Given the flight profile and the helicopter's attitude at the moment of impact, the high horizontal and vertical speed, and the fact that no technical breakdown was found, it can be concluded that the pilot lost contact with the visual references necessary to fly the helicopter, and that he did not see the ground before the impact. 3.0 Conclusions 3.1 Findings The pilot was licensed and qualified to carry out the flight in VFR conditions in accordance with existing regulations. The pilot was not qualified for night flight. The pilot was not trained, experienced, or qualified for instrument flight. The aircraft was certified and equipped in accordance with existing regulations and approved procedures. The on-board systems were examined to the extent possible, and all indications are that they were functioning normally. The helicopter was not certified for IFR flight. Flying the helicopter under instrument flight conditions would have been exceedingly difficult given that the helicopter had no stability augmentation system. The pilot did not request a weather briefing before or during the flight. The MEDEVAC flight took place on a dark night under an overcast sky in marginal conditions. The pilot continued the flight in adverse weather conditions which he was likely not able to recognize because of the low light level. The flight profile and the helicopter's attitude at the moment of impact, and the high horizontal and vertical speed, suggest that the pilot had lost his spatial orientation. The atmospheric interference made HF radio communications practically inaudible. The patient's condition was probably serious, requiring immediate evacuation. The patient's condition likely influenced the pilot in his decision to undertake the night return flight to Kuujjuaq. 3.2 Causes While on a night MEDEVAC flight, the pilot likely lost his spatial orientation when he continued the flight in adverse flight conditions which he was not able to recognize in time because of the low light level. Contributing factors to the accident were that the pilot was not qualified for night flight or for instrument flight, and that the patient's condition likely influenced the pilot's decision to undertake the night return flight to Kuujjuaq for humanitarian reasons. 4.0 Safety Action 4.1 Safety Concerns 4.1.1 System Failure Accidents involving continued VFR-into-IMC account for a disproportionate number of fatalities each year. The causes and contributing factors to these accidents have recurring themes, which are also seen in this accident at Kuujjuaq. In the Board's opinion, these themes include inappropriate pilot qualifications or proficiency for the conditions encountered, and shortcomings in the permissible weather minima for VFR flight, in pilot training, and in pilot licence privileges. In some cases, current industry practices and limitations in aircraft equipment and weather briefing facilities exacerbated the circumstances leading up to the accidents. This preventable accident at Kuujjuaq again underlines several safety deficiencies previously identified by the Transportation Safety Board (TSB) and its predecessor, the Canadian Aviation Safety Board (CASB); these deficiencies represent failures in the system, from pilots' decision making, through the adequacy of companies' operational control, through the provinces' lack of a system for retaining and controlling operators for MEDEVAC flights, through the overall effectiveness of regulatory efforts. 4.1.2 TSB Study of VFR-into-IMC Accidents In 1990, the TSB reported on a safety study of 352 weather-related accidents that occurred between 1976 and 1985 and involved Canadian registered aircraft. (TSB Report No. 90-SP002). The study noted that, whereas 12.7 per cent of all the Canadian accidents during the study period involved fatalities, fully 50.2 per cent of Canadian VFR-into-IMC accidents resulted in fatalities. Almost one-fifth of these accidents involved pilots with more than 3,000 hours total flying time. Whereas charter operations account for less than 19 per cent of all accidents, they comprised almost 27 per cent of the VFR-into-IMC accidents. The accident at Kuujjuaq (A94Q0182) was yet another fatal VFR-into-IMC accident involving a charter pilot with more than 8,000 hours flying experience. The study made 26 safety recommendations aimed at reducing the frequency and severity of such accidents. In the Board's opinion, Transport Canada's (TC) responses to 12 of these recommendations remain unsatisfactory; the responses to another two are considered to be only satisfactory in part. Not all of these recommendations are pertinent to the accident flight; nevertheless, the lack of progress in redressing the underlying safety deficiencies is indicative of regulatory inertia. Appendix A includes a summary and discussion of some of the study's recommendations which are directly pertinent to this accident at Kuujjuaq. 4.1.3 Controlled Flight into Terrain (CFIT) Although the Kuujjuaq accident involved loss of control, given the ambient operating conditions, it could easily have been a CFIT accident. The Board is concerned about the frequency and severity of CFIT accidents involving small commercial operators. Between 01 January 1984 and 31 December 1994, 70 commercially operated aircraft, not conducting low-level special operations, were flown into terrain, water, or obstacles while under control, with no awareness on the part of the crew of the impending impact. Of these 70 CFIT accidents, 35 claimed 106 lives and left 23 persons seriously injured. Two-thirds of these accidents involved aircraft being flown by a single pilot in the sparsely settled areas of Canada. The crew were often attempting to see the ground in order to fly visually, although they were flying in cloud, in the dark, in whiteout, or in other conditions which did not permit visual flight. More than half of these CFIT accidents were conducted under VFR; however, the weather conditions were nearly always below those required by regulations. Over one-third of the CFIT accidents occurred at night (whereas only about one-tenth of accidents involving commercial aircraft in Canada occur at night). In consequence of the foregoing, the TSB is currently completing a safety study into CFIT accidents. Undoubtedly, there will be significant linkages to those aspects of the VFR-into-IMC study which remain unattended. 4.1.4 MEDEVAC Accidents Although this accident at Kuujjuaq was not a CFIT accident per se, it occurred under circumstances very similar to many CFIT accidents involving MEDEVAC flights. A disproportionate number of the CFIT accidents currently being studied occurred on MEDEVAC flights, most of them during dark nights. When CFIT MEDEVAC accidents have occurred, the circumstances were frequently such that the flight crew was attempting the flight with a sense of urgency; this urgency, which compelled the crew to bypass the usual safeguards to expedite the flight, may have been more perceived than real. Most CFIT and VFR-into-IMC MEDEVAC accidents occur in a self-dispatch environment, without the first level of planning and monitoring that an effective dispatcher affords. Between 1976 and 1994, there were 38 occurrences involving aircraft engaged in air ambulance or medical evacuation operations. Fifteen of these accidents took place in Canada's designated North. Helicopters were involved in eight of the accidents. Twenty-one of the MEDEVAC accidents occurred during VFR flights, and 18 occurred during dark nights (i.e., notwithstanding reported flight visibility conditions, the absence of ambient lighting, either from surrounding built-up areas or from the moon, created extra problems for conducting flight by outside visual reference). Twelve of the 38 MEDEVAC accidents were CFIT accidents, 10 of which occurred at night. The TSB's Confidential Aviation Safety Reporting Program has received 17 reports on MEDEVAC operations since 1987. Some of these reports made direct reference to pilots' perceived sense of urgency with respect to MEDEVAC operations. In situations where the conditions are known to be inadequate for the intended flight, crews frequently attempt the flight anyway, with the humanitarian objective to save lives. Confidential reporters also confirmed that the absence of any positive operational control over their flights had an impact, in that it led to a risk-taking attitude under the perceived pressure of the medical emergency. As the National Transportation Safety Board (NTSB) study cited earlier in this report suggests, a strong managerial structure is required to support pilot decision making in the working environment of MEDEVAC operations. 4.1.5 Location of ELT